Carotid Resection Research Articles

Head & Neck Oncology Track: Carotid Resection is an Effect Method for Locoregional Control in Very Advanced Head and Neck Cancer

Head & Neck Oncology Track: Carotid Resection is an Effect Method for Locoregional Control in Very Advanced Head and Neck Cancer

Preoperative Balloon Occlusion Test of the Carotid Artery and Preoperative Tumor Embolization on Paraganglioma of Carotid Body: 20-Year Experience in a Single Institute and Literature Review

Background and Objectives Carotid body paraganglioma is the common type of carotid body tumor for which angiography, carotid artery balloon occlusion test (BOT) and tumor embolization could be considered before the surgery. We analyzed cases in a single institute and reviewed related literature to investigate the necessity of these preoperative examinations.Subjects and Method Medical records of patients who were diagnosed with paraganglioma were retrospectively analyzed from 2000 to 2019.Results Sixteen patients were identified. Of the total, 14 patients underwent surgery at this institute, and 13 underwent angiography. Of the 13 patients who underwent angiography, 6 patients underwent carotid artery BOT, and 12 patients underwent tumor embolization. The average tumor size of 6 patients who underwent carotid artery BOT was 28.7 mm, and 8 patients who did not undergo carotid artery BOT was 30.1 mm. The average tumor size of 12 patients who underwent tumor embolization was 29.4 mm. Two patients did not undergo tumor embolization, and their average tumor size was 30 mm. In 1 patient, both preoperative angiography and carotid artery BOT were performed, but tumor embolization was not performed due to spasm of tumor vessels.Conclusion Preoperative carotid artery BOT can be performed to reduce side effects in patients with the potential for carotid resection. In addition, tumor embolization is performed regardless of tumor size. By reducing the amount of bleeding during surgery and reducing the size of the tumor, it is possible to secure an appropriate surgical field of view to facilitate operation during surgery; however, its effectiveness needs to be clearly identified.

Carotid bypass surgery for a persistent neck tumor after multiple treatments: a case report

Carotid artery involvement in head and neck cancer is challenging for surgeons and oncologists, particularly in recurrence or residual disease following multiple treatments. However, carotid artery resection and reconstruction can be safely performed in a carefully selected patient with local and regional control benefits despite the potential morbidity and high-risk complications. We presented a case of primary laryngeal cancer treated with chemoradiotherapy, modified radical neck dissection type I for residual neck node disease, and further chemotherapy. Although the primary laryngeal cancer showed a complete response, the residual neck tumor was still unresolved and even involved the carotid artery. Therefore, carotid resection with a combined saphenous vein graft and free flap reconstruction was the treatment of choice for this patient. It is effective and safe, and the risk of morbidity has been accepted.

Resection and reconstruction of the carotid artery for head and neck squamous cell carcinoma: a GETTEC study.

Main: To describe 1-year overall survival (OS) after primary or salvage management of head and neck squamous cell carcinoma (HNSCC) invading the common or internal carotid artery (CCA/ICA). Secondary: To assess disease control rate, treatment morbidity, and radio-anatomopathologic correlation. Retrospective study of 67 patients, treated between 1999 and 2020 for N3bM0 HNSCC invading the CCA/ICA as identified by CT-scan. Tumors that could not have been resected with a complete en-bloc resection sacrificing and reconstructing the CCA/ICA were excluded. Patients were separated into two groups (primary or salvage treatment) and studied according to the type of treatment they received: radiotherapy/radiochemotherapy (RT/RCT), surgery, or systemic therapy (ST). For newly treated patients, the 1-year OS was significantly better after RT/RCT (73%) than after surgery (40%, p < 0.0001). In the salvage setting, the 1-year OS after surgery (40%) was better than after ST (14%, statistically suggestive difference with p = 0.0241). Surgery improved cervical control, but distant metastases occurred in more than 50% of cases regardless of treatment. No neurological complication occurred after carotid reconstruction. Perioperative mortality was 7% (1/15). The carotid invasion was confirmed by pathological examination in all five patients with an arterial deformation on CT-scan, in seven among eight patients with CCA/ICA encasement greater than 270°, and in four out of seven patients with CCA/ICA encasement between 180° and 270°. Neck dissection with carotid resection and reconstruction is technically feasible with acceptable neurovascular morbidity. For newly treated patients, survival is better after RT/RCT. For salvage treatment, surgery could be proposed to selected patients.

Near-infrared spectroscopy in head and neck surgery.

Near-infrared spectroscopy is commonly used during carotid endarterectomy but its use in salvage oncological carotid resection has not previously been described. In comparison to other methods of determining the adequacy of contralateral cerebral circulation, near-infrared spectroscopy is simple, reliable, non-invasive and inexpensive.

Multispecialty surgical management of carotid body tumors in the modern era

ObjectiveThe objective of this study was to assess the perioperative and long-term outcomes of carotid body tumor (CBT) resection with a multispecialty (head and neck surgery/vascular surgery) approach. MethodsOur institutional data registry was queried for Current Procedural Terminology codes (60600, 60605) pertaining to CBT excision. These patient records and operative reports were individually reviewed to determine laterality, preoperative tumor embolization, operative time, estimated blood loss, need for intraoperative transfusion, intraoperative electroencephalogram changes, intraoperative division of the external carotid artery, carotid artery repair, resection of the carotid bifurcation, tumor volume, final pathology, cranial nerve injury, stroke, death, and clinical or radiographic evidence of recurrence. ResultsFrom 1996 to 2018, 74 CBT resections were identified in 68 patients (41 [60%] females; mean age, 50.83 years). The mean tumor volume was 9.92 ± 14.26 cm3 (range, 0.0250-71.0627 cm3). Embolization was performed by a neurointerventional specialist in 27 CBT resections (36%) based on size (embolization 14.27 ± 16.84 cm3 vs 7.17 ± 11.86 cm3; P = .063) and superior extension. This practice resulted in one asymptomatic vertebral dissection, which postponed the surgery. There was a trend toward greater blood loss in the embolization group (embolization 437 ± 545 mL vs 262 ± 222 mL; P = .17); however, no transfusions were required in any patient. The mean operative time was also significantly longer in the embolization group (198.33 ± 61.13 minutes vs 161.5 ± 55.56 minutes; P = .03). Three resections had reversible intraoperative electroencephalogram changes, one of which occurred during carotid clamping. These changes resolved with shunting. Eight external carotid resections (11%) and 6 carotid reconstructions (8.1%; two primary, two patch, and two primary anastomosis) were required. Malignancy was identified in four tumors (5.4%), accounting for four of the six carotid reconstructions. There were no postoperative cranial nerve injuries, no strokes, no reexplorations, and no deaths. One patient developed transient dysphagia from pharyngeal tumor infiltration. Long-term follow-up (mean, 43 ± 54 months), available in 61 of the 68 patients (89.7%), revealed three (4.4%) recurrences. ConclusionsThis large, single-institution series demonstrates that a multispecialty team combining two surgical skill sets for the treatment of this rare, challenging condition yields unparalleled low complication rates with short operative times. This approach, including long-term surveillance for recurrent disease, should be considered to optimize outcomes of CBT resection.

The evolving significance of carotid atherosclerosis

What are we to make of the atherosclerotic carotid artery? Initial experience with carotid resection and endarterectomy was reported as early as 1951.1 By the mid-1990s, the North American Symptomatic Carotid Endarterectomy Trial (NASCET)2 and the Asymptomatic Carotid Atherosclerosis Study (ACAS)3 had shown that carotid endarterectomy is superior to best medical management in patients with symptomatic and asymptomatic carotid stenoses.

Clinical features and surgical treatment of neurilemmoma versus carotid body tumors at bifurcation of carotid artery

To analyze clinical features, surgical treatment and outcomes of neurilemmoma and carotid body tumors in bifurcation of carotid artery. The clinical data of 17 patients with neurilemmomas and 76 patients with carotid body tumors at the bifurcation of carotid artery, who were surgically treated in Zhongshan Hospital of Fudan University from March 2012 to November 2016, were retrospectively analyzed. The clinicopathological characteristics, surgical procedures and outcomes were compared between two groups. No difference of preoperative clinical demographic data was found between two groups. Operation time of the neurilemmoma group was significantly shorter than that of the carotid body tumor group[(93.9±30.8) min vs. (159.3±52.9) min, P<0.01]. The neurilemmoma group had lower volume of intra-operative blood loss[(110±96) mL vs. (356±239) mL, P<0.01] and lower rate of external carotid artery resection (11.8% vs. 68.4%, P<0.01) than the carotid body tumor group. In the neurilemmoma group, 17 tumors were completely resected and no malignant disease was found. In the carotid body tumor group, 76 patients underwent complete surgical resection for the tumor, of which 5 (6.6%) were malignant. Tumor size of the neurilemmoma group was larger than that of the carotid body tumor group[(4.5±1.4) cm vs. (3.1±1.0) cm, P<0.01]. There was no significant difference in the incidence of peri-operative complications and length of hospital stay between two groups (P>0.05). The clinical manifestations of neurilemmoma and carotid body tumors at carotid artery bifurcation are similar. The carotid body tumor group has a longer operating time, larger intra-operative blood loss, higher external carotid resection rate and relative higher incidence of malignancy. More cautions should be given when carotid body tumors at carotid artery bifurcation are treated.

NESVS6. Multispecialty Surgical Management of Carotid Body Tumors in the Modern Era

The objective of this study was to assess the perioperative and long-term outcomes of carotid body tumor (CBT) resection with a multispecialty (head and neck surgery/vascular surgery) approach. Our institutional data registry was queried for Current Procedural Terminology codes (60600, 60605) pertaining to CBT excision. These patient records and operative reports were individually reviewed to determine laterality, preoperative tumor embolization, operative time, estimated blood loss, need for intraoperative transfusion, intraoperative electroencephalography changes, intraoperative division of the external carotid artery, carotid artery repair, resection of the carotid bifurcation, tumor volume, final pathology, cranial nerve injury, stroke, death, and clinical or radiographic evidence of recurrence. From 1996 to 2018, there were 74 CBT resections identified in 68 patients (41 [60%] female; mean age, 50.83 years). Mean tumor volume was 84.93 ± 116.15 cm3 (range, 0.2-568 cm3). Embolization was performed by a neurointerventional specialist in 27 (36%) CBT resections based on size (embolization 134 ± 136 cm3 vs 51 ± 84 cm3; P = .005) and superior extension. This resulted in one asymptomatic vertebral dissection that postponed surgery. Blood loss remained significantly higher in the embolization group (470 ± 542 mL vs 227 ± 204 mL; P = .04); however, no transfusions were required in any patient. Mean operative time was also significantly longer in the embolization group (198.88 ± 56.38 minutes vs 153.53 ± 52.45 minutes; P = .00). Three resections had reversible intraoperative electroencephalography changes, one of which occurred during carotid clamping. These changes resolved with shunting. Eight (11%) external carotid resections and six (8.1%) carotid reconstructions (two primary, two patch, two primary anastomosis) were required. Malignant disease was identified in four (5.4%) tumors, accounting for four of six carotid reconstructions. There were no postoperative cranial nerve injuries, no strokes, no re-explorations, and no deaths. One patient developed transient dysphagia from pharyngeal tumor infiltration. Long-term follow-up (mean, 43 ± 54 months), available in 61 of 68 (89.7%) patients, revealed 3 (4.4%) recurrences. This large, single-institution series demonstrates that a multispecialty team combining two surgical skill sets for the treatment of this rare, challenging condition yields unparalleled low complication rates with short operative times. This approach, including long-term surveillance for recurrent disease, should be considered to optimize outcomes of CBT resection.

Multicenter Experience of Surgical Explantation of Carotid Stents for Recurrent Stenosis.

A significant cohort of patients who have undergone carotid artery stenting (CAS) will have in-stent restenosis (ISR). The optimal management of symptomatic or severe ISR remains poorly defined. The purpose of this study was to describe the indications, treatment, and mid- to long-term outcomes of patients undergoing CAS explantation for ISR. All patients undergoing internal carotid artery stent explantation with carotid artery reconstruction at Mayo Clinic Rochester, Dartmouth-Hitchcock Medical Center, and Beth-Israel Deaconess Medical Center from 2003 to 2013 were retrospectively reviewed. Isolated common carotid artery stents were excluded. Demographics, comorbidities, indications for explantation, operative details, and perioperative and postoperative outcomes were reviewed. Over the study interval, a total of 971 patients underwent carotid stenting across the 3 centers. Of these, 8 patients ultimately underwent CAS explantation with carotid artery reconstruction. Mean age was 69 years and 5 patients were male. Index stent placement was for symptomatic stenosis in 4 patients, asymptomatic restenosis after endarterectomy in 2 patients, asymptomatic high lesion in 1 patient, and asymptomatic critical stenosis in 1 patient. Indications for explantation were symptomatic ISR in 4 patients and asymptomatic severe ISR in 4 patients. Method of repair was stent explantation and patch angioplasty in 5 and en bloc carotid resection with bypass in 3 patients. There were no perioperative neurologic events or cranial nerve injuries. At a mean follow-up of 38.7 months, there were 2 late disabling ipsilateral strokes (14.4 months and 19.1 months). A significant cohort of patients who have undergone CAS will have ISR. Although excellent perioperative results after surgical explantation can be obtained, this patient subgroup remains at risk for late neurologic events. Appropriate patient selection and diligent long-term follow-up are mandated to obtain optimal outcomes.

Value of MRI in preoperative evaluation of carotid body tumor

To evaluate the value of MRI in preoperative evaluation of carotid body tumor. A retrospective study was including 32 CBT of 28 patients of carotid body tumor with complete clinical, imaging and pathological data in our hospital. The MRI images of vascular adjacent length, no enhancement vascular wall, carotid displacement, wrapping angle and carotid stenosis were analyzed respectively in tumor resection group, tumor dissection and artery repair group, and tumor and artery resection group. The results were compared with surgery. The indexes of vascular adjacent average length were (3.2 ± 0.8), (3.4 ± 0.7) and (3.8 ± 1.0) cm, respectively.The indexes of vascular adjacent average length and vascular displacement, which all showed no significant difference between each operation group (P=0.577, 0.859). The indexes of no enhancement vascular wall, wrapping angle and carotid stenosis, which all showed significant difference between each operation group (all P<0.01). Compared with the surgical and pathological findings, with no enhancement vascular wall <2/3 circumference as the index of carotid artery repair or resection, the sensitivity, specificity and accuracy were 86.4%, 90%, 87.5% respectively. With wrapping angle >1/3 circumference as the index of carotid artery repair or resection, the sensitivity, specificity and accuracy were 86.4%, 90%, 87.5% respectively. With carotid stenosis as the index of carotid artery resection, the sensitivity, specificity and accuracy were 80%, 100%, 93.7% respectively. The no enhancement vascular wall, wrapping angle and carotid stenosis have a correlation with carotid artery intervention.The no enhancement vascular wall <2/3 circumference, wrapping angle >1/3 circumference and carotid stenosis have a certain value in preoperative evaluation of carotid body tumor, although vascular adjacent average length and vascular displacement have limited value.

Clinical outcome analysis of 47 patients with advanced head and neck cancer with preoperative suspicion of carotid artery invasion.

The purpose of this study was to retrospectively analyze the feasibility of the surgical management of the carotid artery in advanced head and neck cancer with preoperative suspicion of carotid artery invasion. A total of 47 patients were retrospectively analyzed. Twenty-one patients (44.7%) received surgery as initial treatment, and 26 patients (55.3%) had salvage surgical treatment for recurrences. Intraoperative dissection and preservation of the carotid artery was achieved in 39 patients (83%). Eight patients underwent carotid resection with/without reconstruction (17%). The cumulative 2-year and 5-year overall survival rates were 40.4% and 34%, and the disease-specific survival rates were 59.5% and 55.3%, respectively. The overall perioperative mortality rate was 6.4%. Carotid blowout developed in 6 patients. Surgical treatment of the carotid artery in selected patients can provide locoregional control and the possibility of prolonged disease-free survival with acceptable morbidity. © 2015 Wiley Periodicals, Inc. Head Neck 38: E287-E292, 2016.

Combined Balloon Test Occlusion and SPECT Analysis for Carotid Sacrifice: Angiographic Predictors for Success or Failure?

Objectives To evaluate angiographic patterns that may predict the success or failure of carotid artery balloon test occlusion (BTO) and single-photon emission computed tomography (SPECT) analysis for carotid sacrifice. Study Design This is a retrospective nonrandomized study. Study Setting Conducted at the University of California Davis Medical Center, Sacramento, California. Patients A total of 31 patients, ranging from 24 to 83 years of age, with a mean age of 61 years (22 men, 9 women) with head and neck cancer (26 patients), malignant glomus tumor (1 patient) or giant carotid aneurysms (4 patients) as possible candidates for surgical carotid artery sacrifice were evaluated from September 2005 to September 2012. Methods All patients underwent unilateral internal carotid artery balloon test occlusion with SPECT analysis (20 mCi technetium 99m-hexamethyl propyleneamine oxime [HMPAO]) imaging before and during carotid occlusion. Carotid angiography with carotid cross-compression (manual compression of the cervical artery contralateral to the side of contrast injection) was used to analyze filling through the anterior communicating artery to the contralateral hemisphere. Intervention The balloon occlusion was terminated in two patients because of deterioration of the neurologic exam. Main Outcome Measures All patients who passed the neurologic examination during BTO and also passed the SPECT occlusive study underwent successful carotid sacrifice without neurologic sequelae. Patients failing the occlusive neurologic examination and/or the SPECT study elected chemoradiation, with the exception of one patient who underwent a successful carotid bypass graft and carotid resection. Results The success of carotid sacrifice in patients passing both the occlusive test and the SPECT analysis for carotid sacrifice was 100%. Three patients failed both the BTO and the SPECT, with two demonstrating no anterior circulation cross-fill, but one showed some cross-fill. Six additional patients passed the BTO but failed the SPECT, with poor cross-fill in five patients. In addition, three patients who had excellent cross-fill through the anterior communicating artery to the contralateral hemisphere failed the SPECT examination in two cases and failed both tests in another case.

Resection of Unresectable Stage IVB Thyroid Cancer Encasing the Carotid Artery.

Stage IVB thyroid cancer includes carotid encasement or infiltration of the prevertebral fascia and mediastinal vessels. Stage IVB disease is considered unresectable due to grave consequences of attempting resection. We report a rare case of carotid artery engulfment being resected uneventfully without carotid resection.

Late Surgical Outcomes of Carotid Resection and Saphenous Vein Graft Revascularization in Patients with Advanced Head and Neck Squamous Cell Carcinoma

In head and neck squamous cell carcinoma, invasion of the carotid artery is a severe mortality predictor. We report an updated experience of 19 patients who underwent head and neck resection for squamous cell carcinoma with concomitant carotid reconstruction. This study aims to analyze overall survival rates, primary patency of the reconstructions, vascular and nonvascular complications, radiotherapy dosing as well as late follow-up and outcomes. From September 1997 to 2011, 19 patients with advanced squamous cell carcinoma with carotid artery invasion were submitted to resection and concomitant vascular reconstruction in a single referred oncological institution. Patient follow-up was done by means of periodic outpatient returns, where clinical and duplex scan evaluations were performed to study graft patency. The average length of follow-up was 23.3 (± 34.4) months. Nonvascular complications occurred in 6 patients (31.6%). Only 1 (5.3%) vascular complication was observed, resulting from the immediate occlusion of the carotid graft. All patients were submitted to preoperative, adjuvant, or curative intent radiotherapy during the course of the oncologic treatment, with varying doses. Overall disease-free survival, primary patency, and survival with patent graft rates in 5 years are respectively 12.9%, 93.1%, and 13.0%. Three patients (15.9%) are still alive, all without tumor recurrence, and present a disease-free long-term follow-up with patent grafts 21 months, 68 months, and 151 months after surgery. Aggressive surgical approach for patients with advanced squamous cell head and neck carcinoma with carotid invasion can lead to cure in a select group of patients. Saphenous vein grafts demonstrated favorable outcomes with low infection and high patency rates, suggesting a valid alternative for arterial reconstruction in these cases.

Carotid Resection and Reconstruction Associated with Treatment of Head and Neck Cancer

Patients with head and neck cancer may experience carotid artery involvement. We present a series of 10 patients, all with stage IVB disease, who required carotid resection and reconstruction to achieve a complete resection. Nine of the 10 patients had previous radiation treatment to the neck. Six died of distant disease, and three died of other causes with no local or regional recurrences. Carotid resection and reconstruction can be done safely, achieving local and regional control.

An Alternative Surgical Procedure for a Patient with Critically Restenosed and Kinked Carotid Artery: Graft Interposition

According to the literature data, the prevalence of restenosis after carotid endarterectomy ranges between 6 and 36%. The etiological factor is intimal hyperplasia for early period, whereas it is atherosclerosis for late period. A 67-year-old male patient admitted to our clinic with a history of headache and minor stroke. His medical history was significant for right carotid endarterectomy 8 years ago. Recent Doppler ultrasound and digital substraction angiography revealed 75% stenosis and kinking corresponding to the segment distal to the endarterectomy region. Surgical endarterectomy is the treatment of choice in critical carotid stenosis. Endovascular therapy is primarily considered for patients if there is restenosis after carotid endarterectomy. However, the treatment modality is controversial in cases with concomitant carotid stenosis and kinking of internal carotid artery. We present our surgical approach to a case with significant stenosis and kinking of internal carotid artery. We performed a 6-mm-PTFE graft interposition between common and internal carotid artery and resection of the kinking segment.

Treatment of a Ballistic Wound of the Common Carotid Artery Revealed by a Spontaneous Carotid–Jugular Fistula

The case reported is of a 30-year-old patient with a left internal carotid-jugular fistula secondary to the explosion of an improvised explosive device during the Afghan war. Carotid resection with arterial bypass using a venous allograft and internal jugular ligation were performed by left cervicotomy associated with sternotomy at a specialized center. The management of cervical arteriovenous fistulas that occur as a result of penetrating trauma faced during the war must be considered and it should be noted that, on battlefields, treatment is not always performed in specialized units.

Carotid Endarterectomy for Treatment of Instent Restenosis

Carotid stenting is now an established option in the treatment of carotid stenosis. Recurrent stenosis following carotid stenting, however, can be a management challenge. Repeat angioplasty may be ineffective or result in recurrent instent stenosis. Obtaining distal control of the internal carotid artery above the stented segment may be difficult. Instent restenosis was encountered in three patients who underwent successful surgical endarterectomy of the stented segment. A 69-year-old gentleman who had undergone right carotid stenting for a symptomatic >80% stenosis 2 years before presented with symptoms of a right hemispheric TIA manifested by left limb paraplegia. Restenosis of the common carotid artery was identified by duplex ultrasound and confirmed by arteriography. The common carotid was thought to be too tortuous for repeat angioplasty. Operative therapy, therefore, was undertaken. The stent was opened longitudinally with the arteriotomy extending to the distal internal carotid in a standard fashion. Endarterectomy of the plaque and stent was performed around a 12F shunt. The artery was closed with a saphenous vein patch. The stent was well incorporated within the plaque (Fig 1). No cranial nerve deficits were noted. At 30 days the patient was stable with no evidence of carotid stenosis on duplex ultrasound. A 79-year-old gentleman who underwent left carotid stenting for symptomatic severe stenosis presented with recurrent left hemispheric symptoms 4 years later. Severe >90% instent restenosis was noted on duplex ultrasound and confirmed by computed topographic angiography. Carotid endarterectomy was performed around a 12F shunt with removal of the stent and plaque. The artery was closed with a dacron patch. At 30 days, duplex ultrasound revealed no evidence of restenosis. An 86-year-old lady who had undergone right carotid stenting for a symptomatic lesion returned 1 year later with severe symptomatic instent restenosis. Duplex ultrasound confirmed a 75% stenosis at the distal end of the stent. Repeat percutaneous therapy was avoided because of vessel tortuosity and technical difficulties during the first procedure. An endarterectomy of the plaque and stent with dacron patch angioplasty was performed without complication. At 30 days, duplex ultrasound revealed no evidence of restenosis. Considering the popularity of carotid stenting, an increasing number of “high risk” patients are at risk for restenosis. These three patients were all deemed “high risk” for surgical endarterectomy, yet subsequently underwent carotid endarterectomy without complication, calling into question the current inclusion criteria for “high risk” patients. Although carotid resection with interposition graft repair has been described for treatment of recurrent instent stenosis, this is the first report of surgical endarterectomy which includes the stented segment. The stents were easily removed within the endarterectomy specimens using standard surgical technique. These cases demonstrate that carotid endarterectomy can be safely performed for recurrent instent stenosis if the distal end of the stent can be surgically controlled. Longer surveillance is necessary to determine the patency of this procedure.

Relevance of 5 different imaging signs in the evaluation of carotid artery invasion by cervical lymphadenopathy in head and neck squamous cell carcinoma

The aim of this retrospective study was to determine the relevance of 5 different imaging signs in the evaluation of carotid artery invasion. Between September 2001 and September 2008, 22 patients (20 men and 2 women) presented with lymph node metastasis of a head and neck squamous cell carcinoma that invaded the carotid artery. The patients received either carotid artery dissection (CAD, group 1 [n = 17]) or carotid resection (group 2 [n = 5]). Preoperative images using CT (n = 18) and/or MRI (n = 14) were analyzed. In 1 of 17 cases in group 1 and in 5 of 5 cases in group 2, encasement of more than 180 degrees of the artery was present (P < .05). Segmental obliteration of the fat between the lymph node and the carotid artery was noted in 7 of 17 cases in group 1 and for all cases in group 2 (P < .05). Deformation of the carotid artery was reported in no cases in group 1 and in all cases in group 2 (P < .05). The combination of deformation of the carotid artery, encasement of more than 180 degrees of the carotid perimeter, and segmental obliteration of the fat between the adenopathy and the carotid artery was highly predictive of massive invasion of the carotid artery, which would require a resection en bloc. In comparison, the isolated existence of encasement of more than 180 degrees or segmental obliteration of fat could not strictly indicate massive invasion of the carotid artery; thus, CAD could be planned.